Sesamoid AVN Help: Info emailed from patient

For sesamoid AVN, we had a long email correspondence throughout last year :-) the main things that worked were:

- initially, lots of rest, icing, massage

- walking in Hokas and Birkenstock sandals with metatarsal pads

- wearing dancers' pads in the initial stages (but I found that in the later stages they had a tendency to sustain the swelling rather than allowing my foot to press down on the swelling and evacuate it)

- taping my toe down

https://youtu.be/l_4HESXCG40

- doing the toe mobility exercises (from the video that you had sent me)

https://youtu.be/FBTeWbdGrzs

- I also did the Exxogen quite diligently for 4 months, though I'm not sure whether it helped or not (but who knows!)

- and a lot of patience, and trial and error to get things right

Second MRI showed a sesamoid that was fully inflamed, but no more signs of AVN according to my doctor Dr Saxena!

Kind regards,

Old Plantar Fascial Tear: Email Advice

Hi Dr Blake,
I have just experienced a severe pain in my left arch reminiscent to the tear in my plantar fascia from 8 or 9 years ago.  You treated the tear and I was in a boot for 90 days.  Since then I have worn the orthotics you designed...religiously.  No problems until yesterday.  The pain feels like the pain I had years ago just before it tore.
What should I be doing?  I don’t want to go through another torn plantar fascia?
Please respond and let me know next steps.  Your next appointment is not open until 2/8.
Thank you.

Dr. Blake’s comment: It is so important that you create the 0-2 pain level consistently as quickly as possible. If that means you have to be back in a boot until I see you, please do it. Remember to ice 3 times a day 10 minutes each for the next 4 days, than cut to twice a day. No achilles stretching or arch massage until we feel sure it is not a tear. See if anything you are doing really picks on it, and try to avoid for the next 2 weeks. Normally takes 4 to 14 days to either be obvious an injury, or just a small strain of the tissue. Hope this helps. Rich  

Arm Swing: A Vital Part of Pain Free Gait

     When we walk and run, swinging our arms is a vital activity. We need it to free up our hips for instance as the left arm swings and the right hip and leg move, and vice versa. The photo above of a runner clearly shows when the right leg is forward, the right arm is back. Put another way: the right shoulder moves in the same direction as the left hip and leg, and the left shoulder moves in the same direction as the right hip and leg. This contra-lateral rhythm dissipates forces allowing for smooth gait.

     Yet what can upset this delicate balance (and I hope you can appreciate actually how delicate this body is that we live in is)? The simple reason I see day after day is that patients don't move their arms. And when they don't move their arms, stress builds up in the lower extremities. Their hips and knees can start to hurt. Get them to start moving their arms, and they start to feel better. Sometimes, the lack of arm motion is totally due to carrying too much stuff. Backpacks may not be their generation, but they free up the arms, which free up the lower extremities. 

     Since I do gait evaluation on 100% of my patients, I pick up asymmetries in arm motion. It can be from pain in the upper extremity or neck that affects one side. But, this asymmetry can be from uneven foot or leg motion, or compensation from short legs. 

     The moral of this simple story: if patients have lower extremity pain, make sure that they are moving their arms which may help ease their symptoms. 

Sesamoid Fracture in a Dancer: Email Advice

Hello Dr. Blake,

I am a 40 year-old dancer, though not professionally.  When I'm feeling my best, I dance approximately 1 - 1.5 hours per day 3 days per week, take 5 classes one day per week (tap and jazz), and one class on the fifth day of the week (hip hop), giving me two rest days.  

Dr. Blake’s comment: Probably too much at 40, but everyone is so different. Just think about your recovery time. With 5 days of weight bearing activities, definitely the 2 days should not be in a row (like Saturday and Sunday). 

I have injured my left foot three times now.  The first time, when I fell coming out of a turn, there was no reason diagnosis, but after the second injury I recognized it as a turf toe injury.  The second time (aggravated by lots of barefoot jumps and jump turns on hardwood) was diagnosed as metatarsalgia, rule out turf toe, and I did at least 9 months of physical therapy.  I had both a podiatrist and an orthopedist look at my imagining (x-ray and MRI, from what I remember) and neither saw any fractures or anything indicating any significant injury from either the first or second injury.

Dr. Blake’s comment: Accidents happen! Do you think you had fully recovered from these injuries before the latest one? Were you completely pain free and full activity after the second injury? 

Come to October 2020.  During the second half of a 10+ mile hike, on the last day of what became 25+ miles of hiking in Yosemite, I suddenly felt like I was stepping on a bruise.  I recognized the pain as being in the same area.  My doctor recommended conservative management, which I did.  Pain had not improved after one month and so I was seen in urgent care, they did x-rays that the radiologist said showed no abnormalities, and they gave me a post-op shoe to wear and said I was okay to be wearing my work boots.

Dr. Blake’s comment: Sudden pain like this, without a fall, in an overuse situation is a stress fracture until proven otherwise. 

I just saw a podiatrist at the beginning of January 2021.  He told me my lateral sesamoid is fractured and that he thinks it's been there since the first injury.  He did not listen to what I tried to tell him about what happened during the previous treatment.  His only treatment recommendation was to tell me to stop dancing.  Not for a discrete period, but as a blanket statement.  

Dr. Blake’s comment: I hope you can find a real sports podiatrist!!! Terrible advice! Check out the AAPSM website for members near you. 

When I tried to explain the importance of dance, he told me to get dancer's pads and then I could dance again.  He said that I will need to have surgery at some point in the future and told me that he would do a CT to see the level of separation.  He declined to do any additional imaging at that time and told me to keep him updated and that the referral will be active for 3 years.  He didn't want to see anything I've been doing on the meantime, didn't listen to the time I have taken off from dance already, nothing.

Dr. Blake’s comment: The CT is a good idea since you will have more information, although I would like an MRI first. 

I'm trying to figure out the best way forward and have already asked my doctor for a referral for a second opinion, but seeing as most people seem to think this is just some silly hobby, instead of understanding that I'm a hobby athlete and artist in one, it would be very helpful to have some idea what to look for going forward.  I just want to give myself the best possible chance to heal.  These injuries have been very frustrating and it's hard to believe that the only option is to do nothing until I need surgery.  I'm sorry this is so long.  I'm just frustrated and trying to figure out some options so that I can advocate for myself.  I appreciate your time and any assistance you can provide.

Dr Blake’s comment: I know you wanted to tell me your complete story, but try to start with October in a new email. Get an MRI (which you will probably repeat in 6 months) and go into a removable boot for now. You have to get the pain to 0-2 for the next 6 months. You should be icing and contrast bathing each day, and read alittle in my blog on the conservative treatments for sesamoid fractures. Please also get a Vit D level and probably bone density to make sure your bones are healthy.  Rich 

Sincerely,

Plantar Fascia MRI images: Torn Yes or No??

No

No

Yes

Yes

Right and Left Handed: Its Influence on Mechanics

I have had the personal experience of spraining my left ankle in basketball multiple times. It is not fun. You learn, as an athlete, that right handed players land first with their left foot in basketball and that is the typical foot that lands on someone else’s foot and rolls it. This injury influenced by your hand dominance has been a fascination for me in my career of podiatry. It is always fun after watching someone walk to tell them they are left handed and be correct!!!

Right Handed vs Left Handed: Effect on Lower Extremity Biomechanics

 

Ask any ballet dancer if they are dominant on their right or left side because they are right handed or left handed and they will say no!!! They spend their whole careers fighting any dominance of strength and coordination from being right or left handed. But for most of us, we use one side of our bodies a lot better, stronger, gracefully, than the other side. I am right handed and I have long played basketball as if I have no left hand--pretty gruesome sight to behold at times!!

 

If you are right handed, your right side is your movement side (the side you kick the ball with), and your left side is your support side (the one you plant for stability before you kick the ball). And vice versa if you are left handed. And there are shades of this that I see in patients, and myself, from very dominant handed to almost ambidextrous.

 

So a very common pattern of problems I see concerns the instability (weakness) on the support side. This can be very dangerous and slows down or speeds up rehabilitation. For an example, let us take a left ankle sprain in a right handed patient. The injury is to their support leg. The leg they support with is technically injured and unsupportive. And this can dramatically slow down rehab. The more dominant they are to their right side, and the more they rely on the left side for support, the more a left sided ankle sprain is disabling. Patients also hate to make their movement leg into their support leg. It feels so unnatural to them. So, it is much better for a right handed patient to sprain their right ankle, they seem to heal from and handle this injury better. When a right handed patient sprains their left ankle, they must regain that stability as quickly as possible with boots, braces, casts, taping and strengthening exercises. When a right handed patient sprains their right ankle, the goal is protecting it, but emphasizing getting motion back fast.

 

I hope this explains a common problem seen in a podiatry practice when an injury occurs to one side. I like to ask if they are right or left handed to make some correlation with the movement side vs the support side. I have seen many variations of problems created with this phenomenon. Recognizing this syndrome can help in subtle ways patients recover sooner.

This is an excerpt from my book “Secrets to Keep Moving”.

 

High Heel Shoes: Pros and Cons

I remember working with a back doctor, an osteopath by training, who told me that high heel shoes got a bad rap!! She said of her back patients, half felt better in some heel and half needed to wear flats. It depended a lot on the curve of their spine. It definitely got me thinking about general rules that were only half right, but practiced as if it was the gospel of truth. 

High Heel Shoes have been loved and maligned for years. A True Love Hate Affair.

 

From a Podiatrist's perspective, these wonders of the fashion world have many interesting biomechanical aspects. Let me explain the pros and cons of wearing high heel shoes. The possible positive benefits include:

1. Greater Arch Support over Flats
2. Better Forward Shift of Body Weight over Flats
3. A More Relaxed Hamstring, with Less Lower Back Tension
4. With regular use, Foot, Ankle, Knee, and Hip Strengthening
5. Heel Lift producing less strain on Achilles Tendon

But, these are weighed down by the possible negative effects including:

1. Toe box crowding with gradual development of bunions and hammertoes
2. Ankle and Knee in more unstable positions
3. Positional Changes in the Low Back which may produce or aggravate symptoms (increased lordosis).
4. Gradual shortening of the ankle tendon, and hamstrings with possible symptoms.

 

Four very common recommendations for regular high heel wearDrs include: A) stretch the Achilles 3 times daily, B) stretch the hamstrings once daily, C) vary the heel height several times a day, with the lower or higher heeled shoe having more toe box (yes, switch shoes--possibly a chance to shop!!), and D) use bunion protection with medium gel toe separators and Yoga Toes (or knockoffs). I hope these simple, but effective, tips can allow you to wear high heel shoes for many years to come.

The following was adapted from my book “Secrets to Keep Moving”.

Sesamoid Fracture Removal Post-Op Email Advice

Comment from my You Tube channel: drblakeshealingsole

I went 6 months on a fractured sesamoid without knowing it because it was misdiagnosed at urgent care. I then went a year trying the non-invasive treatments (post op shoe, full cam walker, bone stimulator and custom orthotics) before having the sesamoid excised. Now I’m about 2 months post op and I have reduced mobility in my big toe and numbness around the scar and the inside of my big toe near the web. Is this something I’ll have to learn to live with or can I do some specific exercise to gain more mobility and feeling?

Dr. Blake’s comment: I am not a surgeon, but have followed these problems over the years. Post operative healing to me goes in 4 time phases: 

1. First 3 months (Important to measure range of motion and get PT)
2. Next 6 months (3-9 month period post-op) Time where range of motion gains 1-3 degrees per month if that)
3. Next 3 months (9-12 month period post-op) Typically major gains in range of motion 
4. 2nd Year post op (5-10 degrees increase in range of motion can be gained)

     First of all right after surgery that tissue cut has to heal. This healing between the skin and fat layer, fat layer to fascia, joint ligaments, and joint itself gets to work by the inflammatory reaction of the body to trauma and fluid and scar tissue are the major players. Adding to the complexity of healing comes the bell shaped curve of how individual patients respond: some swell a lot and some not at all, some scar a lot and some not at all. And sesamoids have their own biomechanics that can make matters worse post op like:

• Pronation of the foot that is not being controlled with the pre-operative orthotic devices
• The presence of a plantar flexed first metatarsal that needs more dancer’s padding then average (see this all the time in high arched feet for example)
• The presence of very tight achilles and hamstrings that cause more forefoot pressure and should be stretched out

     So, what is the take home with all of this? You are too early in the course to make any conclusions. The reduced mobility is very typically due to both the scarring and swelling. The numbness is probably from the internal swelling pushing on the nerve, but if it was the lateral sesamoid removed, there could be some irritation to that nerve in between the first and second spaces. In general, that symptom resolves, but at times, it deserves some specific treatment. 

     To me, you should improve every month. February for example should be better than January and so forth. Since you have had your stitches out (for those who may not know), you have to work on swelling 3-4 times a day with medications, icing, and contrast bathing. Hopefully, you are in PT, and they are working on the joint range of motion. Have them review my video on Self Mobilization of Hallux Limitus and see if it appropriate. If it is, do it 3 times a day to begin to get the range of motion back. 

     I find that the range of motion (which should be measured monthly) of dorsiflexion naturally increases as you walk with limping more and more, and then run. In fact, sometimes my patients are stuck until they can run. You can also experiment with 1/8 inch padding under the big toe itself to encourage range of motion. 

     This is a perfect time for you to work on the inflammation, range of motion, strength of the foot, protection you get from orthotic devices, etc. I hope this points you in the right direction. Rich 

Bi-Partite Sesamoid versus Fractured Sesamoid? Email Discussion

Hi Dr. Blake,

  I am a 34 yr old active male.  About a month ago I stepped on some glass that had to be removed from my foot.  Flash forward three weeks and I had to get more glass removed by my podiatrist due to pain.  This caused me to favor the ball of my foot under my big toe to avoid the glass that was stuck in my pad under the pinky toe.  I started to notice soreness and tenderness a few weeks after limping on the ball of my foot.  Once the glass was fully removed my stride returned to normal and I began to return to normal exercises, hiking, dog walks and lifting weights.  After a hike 2 weeks ago I was stomping my boots on the ground to get mud off and felt a sharp twinge in the bottom of my foot under my big toe.  The pain quickly subsided on the ride home and I didn't think anything of it until a week later when I noticed some bruising on the outside of my big toe.  Around that time I was having pain in the sesamoid area when walking.  The area became more bruised and swollen over the next few days.  I began RICE, which did help.  I also put myself in a walking boot since I had one from a previous stress fracture on the opposite foot.  Today I had my appointment with a podiatrist and he seems to think my foot is inflamed/swollen from limping on it for a month putting extra pressure on the sesamoid region.  However, my one x-ray reveals a gap in my sesamoid bone.  The doctor thinks it could be a bipartite sesamoid bone or a possible fracture.  He didn't seem too concerned with it being a fracture but said it's possible.  He recommended a walking boot for 3 weeks with an orthotic insert to support.  I have a follow up in three weeks.  My question for you is does it seem like a fracture on that sesamoid or is it a bipartite or a combo (x-rays attached)?  I was hoping for a more concrete answer then maybe or maybe not.  So far pain and swelling with the boot has gone down, still some slight bruising.  I have an appointment with another podiatrist next week, should I ask for x-rays on the other foot to see if I have bipartites in both feet or possibly an MRI?  I've read a lot online and would like to be as proactive as possible with this injury.  Thanks for your time! 

 Dr. Blake’s comment: From my prospective, having seen fractures through bi-partite and tri-partite sesamoids routinely, it would be a dis-service not to get an MRI for a definitive answer. Until then, stay in the boot if it is helping. If you could not get an MRI, these are such problems, that I recommend treating for 3 months in a boot as if you were 100% sure it was broken.  We want to get the pain level to 0-2 quickly for healing. Hopefully, you just bruised the tissue, but even then a month in the boot may be needed. Rich 

Walk Run Program Email Comments by a Patient

Hi there,

Happy new year!  I thought I’d check back and give you a few updates.  

http://www.drblakeshealingsole.com/2020/03/walk-run-program-for-injury.html

The Walk Run program has been going well and I just completed Level 7.  That said, I have noticed a slight increase in pain in the past week or two.  While I used to notice a dull ache (1-2 on scale of 10) every now and again, it has risen to a 1.5-2.5 range and is more constant throughout the day.  Note: I don’t notice it when I’m exercising; it’s more just a slight dull ache I notice as I’m going about my day.  How do these things typically progress?  Should start taking 3 day breaks in between runs to let it rest longer?  (In which case, I’d want to ride my mountain bike in the interim for cardio).  Does the pain eventually go away as my foot strengthens/adjusts or, at some point should we consider another approach?  This foot injury has plagued me for so long that I’m terrified of having a setback or undoing the progress I’ve made so far.  

Dr. Blake’s Comment: You are following the protocol of keeping it at 0-2 during each phase of rehabilitation. Good job!! You definitely have to make a change to knock this pain down. Since you finished level 7, but it sounds like even level 6 may have increased symptoms, I would like you to go back to level 5 for the next two weeks but continue to run every other day. Definitely ice twice the day you run, once right after for 10-15 minutes, and the second 10 minutes in the hour before bed. Email in 2-3 weeks to see if the pain is getting better and we will make appropriate change. But, in general, 2 weeks level 5 and if okay, then 2 weeks at each level moving up to level 10. 

I got the modified orthotics last week - thanks so much!  I tried them out and they felt good but, after a few hours on my feet, my foot felt a little sore (again, like the 2-2.5 range).  I’m not sure if that’s b/c they are harder, b/c the shape differs from my other orthotics, or maybe this just coincided with the above-mentioned pain - but I decide to shelf them for now.  In my mind, I’d best not try them out until my other pain goes away.  Sound good?

Dr. Blake’s comment: Good choice! If they had made an instant improvement, I would have had you use them, but since they did not, let us take that variable off the shelf. Rich 

Thanks,

Capsulitis Pain 2nd MPJ Foot: Video

Hi again Dr. Blake,

I wanted to reach out again, in case you missed my first email.

Also, somehow I said the wrong foot, as it is the second toe in my LEFT foot that I worry might have capsulitis...

Is this something you work with?

Thanks again,

Dr. Blake’s comment: Yes, I have some experience. Make sure you get a Budin splint to start. I am attaching a video that should help. Rich 

https://youtu.be/2dGq6DKbL4U

Sesamoid Fracture: Email Advice

Hello, Dr. Blake! 

I was diagnosed with a sesamoid fracture on Nov. 18th, 2020. Throughout the two months, I have been wearing a walking boot and supplementing calcium, vitamin D, and taking a multivitamin. After two x-rays over the last two months, my doctor told me that there has been minimal healing. 

Dr. Blake's comment: Xray show only solid bone, and most of the initial fracture healing is with new skeletally immature bone that shows poorly on x-ray. Therefore, most agree that x-rays lag 1-2 months behind actual healing. Said in English, if an x-ray shows good healing in March, the bone was probably healed enough in February and probably January. So, minimal healing noted on x-ray is not really the whole story. MRIs are better for fracture identification, when x-rays are inconclusive, but you have to wait 6 months to the validation of some healing. I do x-ray for that information, and I get an MRI for that information, and I treat the sesamoid fracture and the patient based on getting them to be at 0-2 pain level as quickly as possible and then maintaining them at that level for 3 months. 

At my last visit, Jan. 14th, 2021, he felt around my foot and I didn't feel any pain (although he was very gentle). He instructed me to wear regular shoes, and ditch the walking boot so long as there is no pain. He told me to try exercising, but avoid inclines and do not run. If I continue with no pain, then he said it is okay if I go about my life with the bone still fractured. If I experience pain, he plans to take an MRI of my foot on Feb. 10th to see if he needs to remove the sesamoid bone. 

Dr. Blake's comment: I hope you just mis-understood. Continue to wear the boot until 2/18, and if you have taken it off before you read this, add a few more weeks so you can say you wore the boot for 3 months. It takes a year or more to know whether you need surgery. I am assuming that the pain in the 0-2 range while you are in the boot. Between now, and the time you are getting out of the boot, you need to have protective orthotics with dancer's pads to off weight the sesamoids, typically Hoka One One shoes are used due to their rocker. The transition from full time boot to full time out of the boot may take 2-6 weeks on average since pain level has to be your guide. 

It was May 2019 when I originally injured the bone. I noticed the pain when I had finished my third day in a row of working in the same pair of shoes (Chacos, not yet fully broken in). After a few days, the pain subsided for the most part. After several months of sporadic pain, I got an x-ray at a walk-in clinic, and they told me that nothing was wrong. After training for and running a marathon, I finally went to a foot doctor who then found the fracture using x-rays. Throughout the year or so of pain, it was never as painful as the first 24 hours of when it was originally injured. 

Dr. Blake's comment: This is great. Hopefully, the injury, while frustrating will not prove very serious when you get the MRI. You could have a normal bone that lies in multiple pieces that was fractured slightly last May, but now needs a little help to finish the healing. If there is swelling in the tissues, or seen on MRI, then contrast bathing to flush the bone and create better circulation should be done close to every night. 

To be honest, I am afraid of taking my doctor's advice of potentially living the rest of my life with the fracture in my foot. I read on your blog that it takes 2 years in some cases to heal the sesamoid bone, and it is rare that the bone does not heal. I do not want the bone to be removed; I fear the side effects of surgery may be worse than simply living with the fractured foot. Dr. Blake's comment: Yes, you will not live with a broken down. You are too smart for that. You may need an Exogen bone stimulator to help, along with spica taping, cluffy wedges, great off loading orthotics, Dr. Jills Gel Dancer's Padding, etc. 

My purpose in writing to you is to get a second opinion on my doctor's plan for my sesamoid fracture. In the meantime, I plan to wear stiff shoes and use dancer pads to keep the weight off my sesamoids in both feet. I use heat and ice on my foot as well when the swelling feels worse. 

Thank you so much for being the doctor we all need in our lives. I appreciate that you take the time to listen to people and give thorough advice. 

I hope this email finds you well. Dr. Blake's Comment: You are welcome, and good luck Rich 

Sesamoid Fracture to Return to Activity: Email Advice for 12 Year Old

Hi Dr. Blake,
 

I found your information awhile ago when I was researching online about my daughter’s  sesamoid fractures and sesamoiditis. I feel like you know so much about this condition and I was wondering if I could run our situation by you and see if there is anything we are missing or should be doing. We also had an online appt with Caroline Jordan to get some ideas about dealing with a sesamoid injury. 
https://youtu.be/0wAvxIOXY9o

Here is my daughter’s situation - again any advice or thoughts you have are greatly appreciated.

My daughter is 12 years old and plays soccer. I will give you what happened month by month starting in November 2019 until now January 2021. It helps me to keep organized with how everything has gone.

November 2019
-She starting to complain of foot pain toward the end of Fall Soccer season. She had some pain in both feet but more on the right foot. She also had some knee pain. The pain would come and go and did not impact her playing. I knew that she would be getting a good 6 week break from end of November to beginning of January and made an appt with a sports podiatrist that my friend knows and this physician is involved with the podiatry care of a professional football team and seems to have a lot of experience.

Dr. Blake's comment: This was the perfect thinking. 

December 2019
-Had her appointment with the sports
podiatrist and based on the way her foot hits the ground and her mechanics it was recommended to get custom orthotics. She was fitted for the orthotics. She was on break from playing soccer.
-She was given a sort of temporary insert to put in her sneaker and cleat to try to help until her real orthotics came in

Dr. Blake's comment: Also the right idea to try to distribute the weight differently while in the soccer cleat and any training with other shoes. 

January 2020
-She went back to off season training. Her feet and knees were feeling better from the rest. Also, the off season training was 30-50% of the usual fall soccer training, so she was getting more rest days and it was less intense. 
-At the end of the month, her orthotics came in and we also started to find a cleat that would fit the orthotic. 

Dr. Blake's comment: The only thing I would of added is daily icing to cool down any inflammation that had collected during soccer. Inflammation can tend to be stubborn and outlive the periods of rest so it is still there when you return to sports. 

February 2020
-During an outdoor soccer practice, she felt a pop in her right foot when she was making a cutting type of move. She then felt pain. She was still able to finish up practice. At this point we had a follow up appt in one week at the sports podiatrist. Things were very hectic that week and we iced her feet and took that week off from practicing and her feet were feeling better.That weekend though she had 2 futsal games and felt well enough to play. 

Dr. Blake's comment: Some patients pop, snap and crackle alot when there is some inflammation. The fact that she felt well enough to play, and I assume not limp, was still okay. 
-After the 2 futsal games she could not really walk in her feet. Our follow up appt at the sports podiatrist was a few days later and the x-rays revealed 3 fractures in the one of the sesamoids in the right foot. She was put in a boot. No soccer and no exercise.

Dr. Blake's comment: So, this does not sound good, but because sesamoids can be normally in multiple pieces, and MRI has to be ordered to confirm. You also have to treat the worse case scenario which is a fracture of the sesamoid appropriately. I found 3 months in the boot is great for healing. 

March 2020
-Still in a boot
-Follow up appointment was moved back so to lockdown with Covid

Dr. Blake's comment: When a patient goes into the boot, it is to rest the tissue. The pain level in the boot has to be 0-2 for those 3 months. Caroline Jordan's video has alot of exercises you can do to keep strong. Do not do anything that makes the pain increase. 

April 2020
-Was able to get 2 telehealth appts 
-Continuing to wear boot and then toward end of April could start to stop wearing boot.
-Left foot started to hurt but not as bad.

Dr. Blake's comment: While in the boot, if you have been successful at achieving the 0-2 pain level, most podiatrists will start the gradual wean out into shoes and orthotic devices at the 2 to 2 and 1/2 month level. This is fine for some patients and at least rushed for some patients. The doctor always wants to look like a hero in the patient's eyes, but sometimes the patient/parents can be unconsciously making the doctor feel pushed to get out of the cast. This is why I keep my recommendation at 0-2 pain level, and tell the patient that we do not want to start over. 

May 2020
-Some pain still
-got an in-person appt toward the end of month
-x-rays revealed 3 fractures of sesamoid on both the right and left foot. 
-fitted for thick rehab orthotics
-plan is to be out of soccer until Spring 2021 season
-offload feet

Dr. Blake's comment: I am so sure that this was terrible news. However, it is close to impossible to get this scenario. Three fractures on both feet. #1 cause is bilateral tri-partite congenital sesamoids (that got injured). I want an MRI on both feet to know more. 

June 2020
-rehab orthotics came in
-wear rehab orthotics
-off load feet

Dr Blake's comment: I am assuming off load means dancer's padding. 

July 2020
-continue rehab orthotics
-mentally feeling very sad about not being able to play

Dr. Blake's comment: Between the Pandemic and this injury, she must have been very sad. 

August 2020
-continue rehab orthotics
-appointment with Caroline Jordan to see about how to deal with this injury
-started Physical Therapy - working on strengthening overall body while still offloading foot

Dr. Blake's comment: I am so thankful for Caroline. This is the appropriate approach, limit weight bearing, maintain 0-2 pain levels, get cardio and core and lower extremity strength work. I have not mentioned, but get a Vitamin D level to see if she isn't low which could make it hard for bones to heal. Also, remember the 3 sources of pain. Especially after 3 months of an injury, it seems like all 3 can be important to deal with. You are using mechanically treatments, so make sure that you are icing for the inflammation daily, and add one of the nerve treatments like non-painful massage to the area for 2 minutes twice daily. 

September 2020
-continuing Physical Therapy offloading foot and rehab orthotics

October 2020
-X-Rays reveal Right Sesamoid fractures almost healed and Left Sesamoid fractures improving
-Continuing Rehab Orthotics and Physical Therapy offloading feet

Dr. Blake's comment: So, bi- and tri-partite (2 or 3 pieces) congenitally separated sesamoids never start healing. There is no reason to. So, we can assume from this that she had the misfortune of having a rare bone injury. I still want the MRI and now I definitely want to know about her bone health. Also, she sesamoid fractures can be due to hard ground and soccer spikes overloading her bones, was she in a spiked cleat with one of the spikes under the sesamoids. 

November 2020
-Continue Rehab Orthotics and Physical Therapy offloading feet

December 2020
-X-Rays reveal both Right and Left Sesamoid fractures clinically healed
-Physical therapy begins to gradually increase loading feet in small increments

Dr. Blake's comments: Great news, but they can be healed, but very weak due to the off loading. The progression has to be gradual from here, and I wish that there were never any time limit (like unfortunately an upcoming soccer season). So important to not have the pain over 0-2, except for an occasional transitory jab of pain. The coaches and parents have to watch her like a hawk for any limping. Of course, you have to assume it is only 80% healed as you move forward, with ice after sports drills, and no NSAIDs at all which slow down bone healing. 

January 2020
-Physical Therapy continues to increase loading feet and moving towards integrating soccer 
-Physical Therapist and Soccer Coach talk and agree on plan to gradually work on in corporations her back into off season practice drills
-fitted for sports orthotics to fit in cleats
-finding appropriate cleats to wear with sports orthotics

Dr. Blake's comment: This is all perfect. Remember, if there is any increase in pain with practice, she can not participate again until it is back down to baseline (0-2). Some patients are restricted to light drills for awhile every other or every third day. 


So far, she has been to 3 off season practices / her pain level has ranged between a 0-7. Is this normal? Should we get an MRI? What do you suggest we do?
Dr. Blake's comment: This is where the timing of the pain is necessary to advise you. What is the baseline pain during the day? What pain level during weight bearing activities? What is her pain after practice? Is there any swelling or redness? When her pain is over 2, what is she doing? These and any others will be added to this post.  I hope some of my thought process helped. Yes, an MRI of both feet would be great, but you may not need at all now. Since we have both feet supposed with three fractures each, you should answer individually for each foot. Rich 
I really appreciate any thoughts you have on her case.

Sincerely,

The Mom’s response to my questions:

Hi Dr. Blake,

Thank you! Here are the answers to the questions and I have a thought of what might be going on and wanted to see what you think. Everything you mentioned makes sense. I am sorry for the long email. My wheels are turning about a few thoughts I have about what is going on.

Here are our answers, comments, and questions:

1. We are not nearly icing enough. Alicia does not regularly ice. How much should she ice at this point? Should it be done automatically on a schedule or just when she feels pain?

Dr. Blake’s comment: The problem for most patients is that they only do it for pain, instead of trying to avoid the pain of inflammation. Icing a small superficial bone like the sesamoid is maximum 10 minutes, after every time she does anything that could make it hurt (like weight bearing drills), and 3 times a day for now. You never ice before a workout  up to one hour. An ice pack reusable is preferable. 

2. Would our doctor know at this point if the sesamoids were definitely bilateral tri-partite or actually fractures? So if the pieces of the sesamoids merge together it would show healed fractures? I remember our doctor saying he was not sure at first if her sesamoids were naturally in 2 pieces and that some people are born that way. Dr. Blake’s comment: Unfortunately there is no definite here. It is a good sign that the sesamoids showed healing since congenital bi- and tri-partite sesamoids always look broken. It is academic now if she goes back to full activity. However, an MRI should be ordered if you hit a plateau on the healing. 

3. When I keep mentioning offloading I mean to not put more on her feet - she could just do a regular day to day getting around, but no additional weight bearing exercises on her feet. I am not sure if I am using that word correctly. We have never used a dancer’s pad and I am not sure I know what it is. Is it like a cushion you can stick on your foot or in a shoe to kind of act like an orthotic? Dr. Blake’s comment:

See how the dancer’s padding floats the big toe joint

Get Dr. Jill’s Dancer’s padding both right and left and both sizes: 1/8th inch and 1/4 inch. These usually take alittle effort finding the right position for their hole, and discovering which side you need. These however only supplement the dancer’s pad built into the orthotic device, or can be attached later. I will try to show one below that is simply added to the shoe insert. 

4. She did get her Vitamin D Levels checked in August 2020 for her bloodwork for her well visit and her Vitamin D levels were normal.

Dr. Blake’s comment: With Vitamin D, I always want to know the value and the normal range for the lab she got it!! Very important that athletes function at the middle of that range, not at the low end of normal. 

5. How do you do the nerve treatment of non-painful massage? Do patients do it thenselves? I know that the physical therapist did more of that in the beginning of physical therapy. He also did cupping on the sesamoid area, which he could not give definite feedback that it was really doing something, but he has had positive feedback from his patients. My daughter says that cupping makes her feet feet feel better, but they are doing it less and less now. Dr. Blake’s comment: Sorry, I have no experience with cupping for a sesamoid injury. Does not make sense to me, but having no experience really does not qualify me to comment. Neuropathic treatment for right now is just her taking the palm of her hands and some hand or face lotion and massaging the area for 2 minutes. As long as the area does not hurt, the biofeedback to the brain is that she is fine and the sometimes hyper sensitive nerves in the area relax. 

6. I remember that our doctor did not want to bring her mood down because she was already so upset. He told me when she was not in the room and after the x-rays showed healing that he was so happy her x-rays showed healing because this was a bad injury. 

Dr. Blake’s comment: Sounds like a very deceit human being!!

7, Our doctor also told me that the reason these fractures happened was due to the way her foot hits the ground when she runs and that this sesamoid area was receiving so much more grinding every time she runs that it was just a matter of time that fractures were going to happen. My understanding was that the only way we could have avoided this was get her into orthodics as soon as she started to play sports when she was little. He also mentioned that basically we have to protect her from herself - meaning her mechanics and structure was causing this so we need to use orthodics, correct footwear, adding more rest days, going by what her feet feel like. That she is going to be the player that will be icing more, stretching more, may need to take days where she watches practices because her feet need to rest, that she may need to do other forms of cardio like biking instead of more running to balance her feet and she may have to plan her activities to make sure she is giving herself the best options to play.

Dr. Blake’s comment: Sounds incredible!! A very good plan moving forward. 

8. She was wearing cleats with the spike under the sesamoid. I am finding most cleats have a spike in that area - is there any cleats that do not have that spike there? Our doctor wanted her to start with turf shoes. We got her both cleats and turf shoes. She said that the turf shoes are not comfortable at all and her feet feel worse and feels like she cannot move the way she wants to. Both of the cleats and turf shoes are able to fit her rehab orthotics. Dr Blake’s comment: I usually remove one half of the cleat at the start. This is a cleat related problem for sure. The turf shoes is a good idea, but dancer’s padding is needed. If you remove half of the cleat under the sesamoid, and spend some time in practice in the turf shoes, she will be having a lot less stress on the sesamoids. 

9. Here are pain levels and when:

Just relaxing or doing things at home - 0-3

Soccer and Running - can go up to 7 Dr. Blake’s comment: (this is where the sesamoid is still being overloaded)

If it goes up to 5-7 it may last 1-2 hours after practice. It is back to 0-2 when she wakes up the next morning, Dr. Blake’s comment: This is a great sign!! More icing after practice, 2 hours later, and right before bed. She can try icing for 20 minutes 2 hours before practice to see how she does. 

The 7 pain level had been when using her regular sneakers with the rehab orthodic during the indoor practice on a kind of turf rug. They cannot wear cleats in the indoor places where they are training. Dr. Blake’s comment: Here she is most vulnerable. She may need in this environment the addition of Dr. Jills Gel Dancer’s Padding, spica’s taping and cluffy wedges (which are all in my blog—use the search area). She may also need to change the orthotics or shoes. 

She says she feels her rehab orthodics shift in her sneakers when she is doing soccer moves. Dr. Blake’s comment: Probably have to be redone full width of the sneaker (can send the lab the sneaker insert). If the lab is redoing for more width, have the doctor decide if more arch and more dancer’s padding (called Reverse Morton’s Extension) can be added. 

She says the cleats with the orthodics feel better than when she is exercising in her sneakers with the rehab orthotics. Dr. Blake’s comment: It is always good that one mechanical environment actually feels better than another. This means mechanical changes can help. Something has to be done to the other environment to make them equal. 

This is only for the right foot. She says her left foot has been fine. Dr. Blake’s comment: Hooray!! However, unless there is a reason, whatever you do to the right at least half should be done on the left for balance. 1/4 inch dancer’s padding right should be balanced by 1/8 inch dancers padding left. 

She has never noticed any swelling or redness in either feet. Dr. Blake’s comment: When dealing with sesamoid fractures, they should produce an inflammatory response. Did anyone ever comment on any swelling in this process? 

She also told me that her rehab orthodics in her sneakers used to feel better when she first got them. Dr. Blake’s comment: This needs to be investigated. 

10. She walks barefoot in the house - she says it is more comfortable. Is this ok to do? Dr Blake’s comment: Get some Oofos sandals for the house to protect these feet.

11. Could this be what could be causing the problems right now in practice or aggravating things:

- if her Rehab Orthodics are shifting when she is trying to do indoor training - could it be not off loading due to bumping into the sesamoid area? Correct

- is the reason she is doing a little better with the cleats outdoors is because the cleats are new and holding the rehab orthodics in place more so they are doing their job better off loading? Correct, and the ground gives more!!

- the x-rays show she is still growing - if her feet grew a little could the sesamoid area of the orthodic not be in the right place and not off loading like it should? Typically dancer’s padding that float the sesamoids are pretty big. However, do the lipstick test for me. Put a little lipstick (any shade will do!!LOL) on a que tip (sp??) and mark the exact spot she hurts. Then place her foot into the shoe and see where the mark ends up as far towards the toes. Ignore any smug mark getting the lipstick mark in the shoe. This will tell you exactly where to put the dancer’s padding to protect the sesamoid. You can of course due this better if you remove all the laces. 

- she just got fitted for sports orthodics but maybe if her feet grew she is going to need a mew pair of rehab orthodics as well. 

- is this just too much too soon - should she be taking the steps to get back more slowly?

Dr. Blake’s comment: This is a busy time in the rehabilitation and getting the pain down to 0-2 for all activities is ideal. I do not want these 3-7 pain levels at all. You may have to step back from those activities until orthotics are changed, you shave the spike, you learn to spica tape, you ice more, you learn cluffy wedges, etc. 

- should she hold off on soccer practice or monitored running at physical therapy until it is determine if she did grow and the orthodics are shifting or that the shoes are a little looser from wearing them for a number of months and making the orthodics shift? Do the lipstick test, get the orthotics wider, add the dancer’s pads, etc. 

- with the sesamoid area on the orthodics - do you need to be more vigilant about making sure that she has not grown and moved out of that sesamoid off loading area?

-should I push to get an MRI at this point? Dr. Blake’s comment: I am not sure what the MRI would tell us over the above discussion. However, in treating sesamoids, I always tell patients when they get an MRI it is there first of at least 2. The second one is 6 months down the line to check healing. We can assume good healing now and that the right biomechanics and inflammatory and neuropathic treatments are not yet in place. If you get them in place, and you still can not keep the pain between 0-2, MRI is completely indicated. I sure hope this has been helpful. Rich 

Again thank you so much!